Resynchronization method and apparatus based on intrinsic atrial rate

ABSTRACT

A method and system for setting the operating parameters of a cardiac rhythm management device in which a plurality of parameter optimization algorithms are available. A measured feature of an electrophysiological signal such as QRS width has been shown to be useful in selecting among certain parameter optimization algorithms. In one embodiment, one or more resynchronization pacing parameters are set based on one or both of the feature extracted from an electrogram signal and the value of a resynchronization pacing parameter which tends to minimize the intrinsic atrial rate.

CROSS-REFERENCE TO RELATED APPLICATION(S)

This application is a continuation of U.S. patent application Ser. No.10/624,458, filed on Jul. 21, 2003, now issued as U.S. Pat. No.7,231,248, which is a continuation of U.S. patent application Ser. No.09/995,255, filed on Nov. 27, 2001, now issued as U.S. Pat. No.6,597,951, which is a continuation of U.S. patent application Ser. No.09/810,082, filed on Mar. 16, 2001, now abandoned, the specifications ofwhich are incorporated herein by reference.

TECHNICAL FIELD

The present invention relates to pulse generators and in particular tothe selection and control of executable protocols of the implantablepulse generator.

BACKGROUND

Cardiac rhythm management devices are devices that treat disorders ofcardiac rhythm and include implantable pulse generators such aspacemakers and implantable cardioverter/defibrillators that provideelectrical stimulation to selected chambers of the heart. A pacemaker,for example, is an implantable pulse generator that paces the heart withtimed pacing pulses. The most common condition for which pacemakers areused is in the treatment of bradycardia, where the ventricular rate istoo slow. Atrio-ventricular conduction defects (i.e., AV block) that arepermanent or intermittent and sick sinus syndrome represent the mostcommon causes of bradycardia for which permanent pacing may beindicated. If functioning properly, the pacemaker makes up for theheart's inability to pace itself at an appropriate rhythm in order tomeet metabolic demand by enforcing a minimum heart rate.

Also included within the concept of cardiac rhythm is the degree towhich the heart chambers contract in a coordinated manner during acardiac cycle to result in the efficient pumping of blood. The heart hasspecialized conduction pathways in both the atria and the ventriclesthat enable the rapid conduction of excitation (i.e., depolarization)throughout the myocardium. These pathways conduct excitatory impulsesfrom the sino-atrial node to the atrial myocardium, to theatrio-ventricular node, and thence to the ventricular myocardium toresult in a coordinated contraction of both atria and both ventricles.This both synchronizes the contractions of the muscle fibers of eachchamber and synchronizes the contraction of each atrium or ventriclewith the contralateral atrium or ventricle. Without the synchronizationafforded by the normally functioning specialized conduction pathways,the heart's pumping efficiency is greatly diminished. Patients whoexhibit pathology of these conduction pathways, such as bundle branchblocks, can thus suffer compromised cardiac output.

Heart failure is a clinical syndrome in which an abnormality of cardiacfunction causes cardiac output to fall below a level adequate to meetthe metabolic demand of peripheral tissues and is usually referred to ascongestive heart failure (CHF) due to the accompanying venous andpulmonary congestion. CHF can be due to a variety of etiologies withischemic heart disease being the most common. Some CHF patients sufferfrom some degree of AV block or are chronotropically deficient such thattheir cardiac output can be improved with conventional bradycardiapacing. Such pacing, however, may result in some degree ofuncoordination in atrial and/or ventricular contractions due to the wayin which pacing excitation is spread throughout the myocardium. Theresulting diminishment in cardiac output may be significant in a CHFpatient whose cardiac output is already compromised. Intraventricularand/or interventricular conduction defects (e.g., bundle branch blocks)are also commonly found in CHF patients. In order to treat theseproblems, cardiac rhythm management devices have been developed whichprovide electrical pacing stimulation to one or both ventricles in anattempt to improve the coordination of ventricular contractions, termedcardiac resynchronization therapy.

SUMMARY

The present invention is a method and system for optimizing theoperating parameters of a cardiac rhythm management device such as animplantable pulse generator in which a plurality of optimizationalgorithms are available. Such operating parameters may include, forexample, the programmed AV delay and, if biventricular pacing is allowedby the physical configuration of the device, which ventricles to paceand the offset between ventricular paces. Optimization algorithmsusually represent methods for setting parameter values that haveempirically been shown to be effective in improving the cardiac statusof at least some patients. Such algorithms reach a decision based uponvarious inputs including the physical configuration of the device,variables measured by the device, and patient data otherwise collected.Parameter optimization algorithms usually do not, however, produceinformation that is helpful in selecting which among a plurality ofavailable algorithms is the optimum one to use in a given situation. Inaccordance with the invention, an indication of the degree ofventricular asynchrony existing in the patient is used to select anoptimization algorithm. Other factors that may influence the selectioninclude the physical configuration of the device and whether a selectedalgorithm produces parameter settings that are within allowable ranges.

In an exemplary embodiment, two parameter optimization algorithms areavailable. One algorithm adjusts the operating parameters in a mannerthat maximizes cardiac output while the other adjusts the operatingparameters so as to maximize myocardial contractile function (i.e., thestrength of systolic contractions). The former may be implemented by apulse pressure optimization algorithm since systolic pulse pressure isdirectly related to cardiac output at a given heart rate. An indirectway of determining pulse pressures produced by an atrial-triggeredventricular pacing mode with particular parameter settings is to measurethe intrinsic atrial heart rate produced by the patient's baroreceptorreflex. The pulse pressure optimization algorithm may then recommend thebest parameter settings as determined from a series of trials, where thesettings may include AV delay and/or which chambers to pace. The otheroptimization algorithm is one that adjusts the AV delay based upon ameasured intrinsic atrio-ventricular conduction time (e.g., a PRinterval on an electrogram). Parameter settings produced by such analgorithm have been shown to maximize myocardial contractile function asreflected by the rate of change of systolic pressure. In accordance withthe invention, an indication of the degree of ventricular asynchronyexhibited by the patient is used to select between the two optimizationalgorithms in a given situation. The morphology of an intrinsic QRScomplex, or its equivalent in an electrogram, can be used as oneindication of ventricular asynchrony. The width of the QRS waveform, asdetermined either from a single representative sample or from an averageof such samples, is indicative of any delays that exist in ventriculardepolarization. In a particular embodiment, the pulse pressureoptimization algorithm is used in preference to the contractilityoptimization algorithm when the QRS width indicates a relatively largedegree of asynchrony.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a flowchart showing one embodiment of the present subjectmatter;

FIG. 2 is a flowchart showing one embodiment of the present subjectmatter;

FIG. 3 is a flowchart showing one embodiment of the present subjectmatter;

FIG. 4 is an illustration of a cardiac signal according to the presentsubject matter;

FIG. 5 is a decision tree flowchart showing one embodiment of thepresent subject matter;

FIG. 6 is a schematic drawing illustrating one embodiment of a system ofmedical device programmer and an implantable pulse generator coupled byleads to a heart; and

FIG. 7 is a block diagram illustrating one embodiment of controlcircuitry of the system according to the present subject matter.

FIG. 8 illustrates an exemplary procedure that may be executed by one orboth of the devices illustrated in FIG. 7.

DETAILED DESCRIPTION

In the following detailed description, references are made to theaccompanying drawings that illustrate specific embodiments in which theinvention may be practiced. Electrical, mechanical, programmatic andstructural changes may be made to the embodiments without departing fromthe spirit and scope of the present invention. The following detaileddescription is, therefore, not to be taken in a limiting sense and thescope of the present invention is defined by the appended claims andtheir equivalents.

Advances in implantable pulse generators have lead to devices thatcontain multiple optimization algorithms for providing pacing anddefibrillation pulses. Many of these optimization algorithms haveimproved resynchronization parameter values that are set automaticallybased on information sensed or derived from the patient. Examples ofsuch optimization algorithms include pulse pressure optimization (PPO)algorithms that determine improved settings based on candidatetherapy-induced changes in heart rate and attempt to improve pulsepressure, maximum pressure versus time algorithms (Max dP/dt algorithms)that determine settings by measuring intrinsic atrio-ventricular (AV)conduction times and attempt to improve the left ventricular contractilefunction. Other examples of optimization algorithms exist.

One example of an optimization algorithm is U.S. Pat. No. 5,800,471entitled “Method for Optimizing Cardiac Performance by Determining theOptimal Pacing Mode-AV Delay from the Transient Heart Rate Signal forUse in CHF, Brady, and Tachy/Brady Therapy Devices” (hereinafter “the'471 patent”) that is hereby incorporated into the present applicationin its entirety. The '471 patent describes a cardiac rhythm managementdevice that includes a dual chamber pacemaker especially designed fortreating congestive heart failure. The device incorporates a programmedmicrocontroller that is operative to adjust the pacing mode-AV delay ofthe pacemaker so as to achieve improved hemodynamic performance. Atrialcycle lengths measured during transient time intervals immediatelyfollowing a change in the mode-AV delay configuration are signalprocessed and a determination is then made as to which particularconfiguration yields improved cardiac performance.

An additional example of an optimization algorithm is U.S. Pat. No.6,144,880 entitled “Cardiac Pacing Using Adjustable Atrio-VentricularDelays” (hereinafter “the '880 patent”) that is hereby incorporated intothe present application in its entirety. The '880 patent is an exampleof maximum pressure versus time algorithms (Max dP/dt algorithms) thatdetermine settings by measuring intrinsic atrio-ventricular (AV)conduction times and attempt to improve the left ventricular contractilefunction. The '880 patent provides a pacing system for providing optimalhemodynamic cardiac function for parameters such as contractility (peakleft ventricle pressure change during systole or LV+dP/dt), or strokevolume (aortic pulse pressure) using calculated atrio-ventricular delaysfor optimal timing of a ventricular pacing pulse. The '880 patentdescribes multiple ways to provide optimized timing for ventricularpacing by determining certain intrinsic electrical or mechanical eventsin the atria or ventricles that have a predictable timing relationshipto the delivery of optimally timed ventricular pacing that maximizesventricular performance. This relationship allows for a prediction of anatrio-ventricular delay used in delivery of a ventricular pacing pulserelative to a sensed electrical P-wave of the atrium to establish theoptimal pacing timing.

One issue with implantable pulse generator systems that have multipleoptimization algorithms is how to select the most appropriate method forthe patient from the optimization algorithms. Many times, this selectionis done by the physician at the time of implanting the device or duringa follow-up visit with the patient. This selection process is oftenaccomplished based on limited technical and patient specific informationrecorded and stored in the device. The present subject matter provides amethod and a system for automatically presenting the most appropriateoptimization algorithm from multiple optimization algorithms at the timeof therapy programming.

The present subject matter provides the following important steps andconsiderations. First, pertinent information is collected from thepatient. This information includes, but is not limited to patient datastored in their implantable device, such as the position of one or moreimplanted leads (e.g., position adjacent the mid-lateral wall of theleft ventricle and/or the mid-septum of the right ventricle), thechamber, or chambers, where a lead is permanently implanted (in rightventricle, adjacent a left ventricle or both right and left ventricles).In one embodiment, the position of the implanted lead(s) and where theleads are implanted are acquired from the patient data. In anotherembodiment, the position of the implanted lead(s) and where the leadsare implanted are determined by analyzing the electrogram and timing ofelectrical signals recorded on the various leads to predict theirpositions based on calculated conduction times and cardiac impulsesignal morphology. The information further includes current devicesettings such as current lower rate limit, AV-delay values, LV-offsetvalues (when pacing in right and left ventricle, where the LV-offsetvalue is the time between when the right ventricle pacing pulse isdelivered to the time the pacing pulse to the left ventricle isdelivered), rate responsive parameters, minute ventilation data andconduction pattern data recorded from surface ECG or intracardiacelectrograms (e.g., intraventricular timing, timing of the sensedQRS-complex and the duration interval of sensed QRS complexes). Thisinformation is entered by the physician, retrieved from previouslystored data in the implantable pulse generator, or recordedautomatically from the patient by sensing from the pulse generator orthe external programmer.

Second, the most appropriate optimization method is automaticallyselected based on the patient information. In one embodiment, this isdone through the use of a decision tree algorithm executed in either theimplantable pulse generator, under the control of a medical deviceprogrammer, or executed in the medical device programmer itself. Third,once the optimization method is selected the program parameters areselected, adjusted and the program is executed in the implantable pulsegenerator or programmer. Examples of the optimization methods include,but are not limited to, PPO algorithms and Max dP/dt algorithms, andother optimization methods that are used to maintain and/or improvecardiac function and are considered to be useful with the presentsubject matter.

Finally, the optimization results provide a value, or values, for one ormore parameters of the optimization method. For example, in the case ofthe PPO algorithm, a determination and suggestion as to which chambersto pace and AV-delay would be made through the testing process of thealgorithm. In addition, the Max dP/dt algorithm would go throughmultiple parameters and suggest settings for providing the mostdesirable output. This information is combined with all, or some, of thepatient information to provide final parameter settings orrecommendations, or to adjust and re-execute the optimization method, orto select and execute a new method, as necessary. The parameter settingsallow for improvements in cardiac function, which include, but are notlimited to, efficiency of the heart (relation between output and howmuch energy is expended per heart beat), maximum output of the heart,improved average work produced, and improved peak work done by theheart.

In the present subject matter, various information is measured either bya medical device programmer, or input by a physician. In one embodiment,this information includes the measurement of a cardiac depolarizationcomplex (i.e., QRS complex). This measurement is done either by thephysician, automatically by the medical device programmer or the pulsegenerator. The QRS complex can be measured from a surface ECG recordingmade by the physician with an external electrocardiographic machine orby the programmer automatically when attached to the patient surface ECGleads. Also, the equivalent of a QRS complex can be measured fromimplanted lead electrocardiogram signals by the pulse generator or bythe programmer from telemetered pulse generator electrogram signals.Based on a selection as to which improved resynchronization parametervalues are desired, the present subject matter determines whichalgorithm needs to be executed. As previously discussed, examples ofsuch optimization algorithms include pulse pressure optimization (PPO)algorithms that determine settings to improve pulse pressure based onchanges in heart rate induced by candidate therapies, and maximumpressure versus time algorithms (Max dP/dt algorithms) that determinesettings to improve the left ventricular contractile function bymeasuring intrinsic atrio-ventricular (AV) conduction times. The cardiacfunction of the patient is then managed by controlling the pulsegenerator parameters that control, for example but not limited to,average cardiac output, maximum cardiac output and/or energy efficiency.

The present subject matter can be implemented in either an implantablemedical device, such as an implantable pulse generator, or in anexternal medical device programmer. It can be used at patient follow-upsin the clinic to assist in the optimal programming of the device, or itcan be executed automatically in the implanted device when the patientis outside the clinic, as part of an ambulatory, automatic optimizationsystem.

FIG. 1 shows one embodiment of a method according to the present subjectmatter. At 100, at least one cardiac signal is sensed from a heart. Inone embodiment, the cardiac signal is sensed from a right ventricle. Inan additional embodiment, the cardiac signal is sensed from a leftventricle. Alternatively, the cardiac signal is a surface ECG sensedthrough the use of a medical device programmer that is adapted to senseand receive a surface ECG. The types of cardiac signals sensed from theright or left ventricles include unipolar signals or bipolar signals,where the signals are either far field (morphology) or near field(rate).

At 120, one or more features are measured from the sensed cardiacsignal. In one embodiment, the features measured from the cardiac signalinclude, but are not limited to, a duration interval of a QRS complex.In addition, the features include, but are not limited to, informationderived from two or more cardiac signals. For example, cardiac signalsare sensed from both the right and left ventricles, where a timing delaybetween the contraction in one of the left or right ventricle and theright or left ventricle, respectively, is taken as the measured feature.In an alternative embodiment, the one or more features could alsoinclude blood pressure measurements take from the arterial side of thevasculature, for example with a finger plethysmography sensor.Alternatively, the features could include information related to bloodchemistry (e.g., concentrations and/or the presence of specific chemicalcompounds in the blood). This type of information is also useful indetermining the type of optimization method to suggest.

At 140, a cardiac optimization method is then selected from two or morecardiac optimization methods based in part on the measured features fromthe cardiac signal. In one embodiment, the selection of the cardiacoptimization method is based on programmed criteria that provide ahierarchy of the cardiac optimization methods, where given specificfeatures measured from the cardiac signal, or signals, one or morecardiac optimization methods are suggested over one or more othercardiac optimization methods. For example, given the features measuredfrom a patient's cardiac signal, optimizing the AV-delay may takeprecedence over optimizing which ventricular chamber should be paced orwhat value to set for an LV-offset. At 160, parameters that are to beused by the selected cardiac optimization method are analyzed todetermine whether their values would be within acceptable ranges forprogramming the implantable pulse generator. Based on this analysis,various recommendations are made with respect to programming the pulsegenerator. For example, when the parameters fall outside of theacceptable value ranges for the pulse generator, the execution of theoptimization method is discontinued and no recommendation is made.Alternatively, adjustments to the parameter values are made, and/orsuggested, so as to place the parameter values back within acceptableranges. Finally, adjustments are made to the remaining portion of theoptimization method to only use combinations of the parameters that arewithin the acceptable range. At 180, the selected cardiac optimizationmethod is then executed.

FIG. 2 shows an additional embodiment of a method according to thepresent subject matter. In one embodiment, the subject matter shown inFIG. 2 allows for features measured from the cardiac signal during theoptimization method to be combined with additional patient informationto allow for adjustments to be made to the operation of the cardiacoptimization method. In one respect, the sensed features and patientinformation is fed back into the operation of the cardiac optimizationmethod to allow for patient specific adjustments to be made to theoperation of the cardiac optimization method.

At 200, one or more features are measured from a cardiac signal duringthe execution of the selected cardiac optimization method. In oneembodiment, the one or more features are the features measured and usedin identifying which cardiac optimization method to execute, aspreviously described. The one or more features are then recorded at 210during the execution of the cardiac optimization method. In addition torecording the features, additional patient information is acquired at220 during the execution of the cardiac optimization method. In oneembodiment, the additional patient information includes, but is notlimited to, patient data stored within the implantable device, such asthe location of leads implanted in the patient's heart and the numberand type of electrodes located on the leads, patient medical history,current device settings, event counters and histograms, and conductionpattern data, such as QRS-complex duration interval. Other types ofadditional patient information are also possible.

At 230, the recorded features measured during the cardiac optimizationmethod, additional patient information and device parameter settings areused to adjust the execution of the cardiac optimization method. In oneembodiment, adjusting the optimization method includes selecting andsetting final parameter settings for the cardiac optimization methodbased on both the additional patient information and the recordedfeature measurements. The final parameter settings that result from thefeatures measured during the optimization could result in recommendedparameters that may not be acceptable for programming of the implantablepulse generator. One example of this is that the combination ofrecommended AV delay and LV offset parameters could place the laggingventricular pace outside of the range that is generally accepted. Ifthis is the case, there are three multiple options available as how toadjust the execution of the optimization method. Three options arediscussed here, but there are other methods available that are notdiscussed here. The first method is to discontinue the execution of theoptimization thus providing no recommendation. The second is to adjustone or more of the parameters to place possible recommendations backwithin the range that is generally accepted prior to continuing thecardiac optimization method. The adjustment of the parameters could beautomatic, or based upon input from the user. The third is to modify theremaining portion of the optimization method to only use combinations ofthe parameters that are within the acceptable range.

In an additional embodiment, the final parameter settings are used insubsequent determinations of parameter values for a differentoptimization method or other programmable feature of an implantablepulse generator. So, for example, an optimization method and parametersettings are determined for an AV-delay to use with the patient. Oncethis is determined, the parameter settings used in determining theAV-delay are used in the system to then determine an LV-offset value.Once the LV-offset value is determined, a third cardiac optimizationmethod can then be used to determine a set of third parameter values touse in conjunction with the parameter values of the previous two cardiacoptimization methods. In one embodiment, this type of serialdetermination of parameter values has a hierarchy of items to addressand step through sequentially to determine each one and see how each onechanges with respect to this value just determined.

In an alternative embodiment, additional adjustments are made to thecardiac optimization method based on the measured features and thepatient information. For example, a particular range of values for acardiac optimization method might be suggested, where the range ofvalues is selected to present the values most likely to improve thepatient's heart function, thereby saving the physician time inprogramming the implantable pulse generator. In an additionalembodiment, the feature measurements and the additional patientinformation is used to trigger a re-execution of the cardiacoptimization method. Alternatively, information from the featuremeasurements and the additional patient information is used to selectand execute a second cardiac optimization method from the multiplecardiac optimization methods.

FIG. 3 shows an additional embodiment of the present subject matter. Aspreviously discussed, a cardiac signal is sensed at 300. At 310, one ormore features are measured from the sensed cardiac signal, where in thepresent embodiment the measured feature is a duration interval of a QRScardiac complex. At 320, the duration interval for the QRS cardiaccomplex is then compared to a series of recorded values. In oneembodiment, this comparison results in the duration interval of the QRScardiac complex being classified as having either a short, a medium or along duration interval. For the present subject matter, the durationintervals of the QRS cardiac complexes are measured in milliseconds,where a short duration interval for the QRS cardiac complex is less thanor equal to 150 milliseconds, a medium duration interval is greater than150 milliseconds and less than or equal to 160 milliseconds, and a longduration interval is greater than 160 milliseconds.

In one embodiment, the QRS duration is measured at each follow-up visitof the patient. One reason for this is because presently there isinsufficient information about how the QRS duration changes with chronicpacing therapy. In one embodiment, the QRS duration is measured from thepatient through the use of a 12-lead ECG, where the QRS duration ismeasured from any of the 12 leads. In one example, the QRS duration istaken from the lead having the maximum QRS duration. In an alternativeembodiment, the QRS duration is measured from cardiac signals sensedfrom leads 11, V1 and V6. Regardless of the lead, the QRS duration canbe measured manually on a paper strip chart recording at a rate of 50mm/second using standard practice for determining the start and end ofthe QRS complex. In an alternative embodiment, the duration interval ofthe QRS complex is measured automatically by the medical deviceprogrammer as the cardiac signals are sensed from the surface ECGsignal. Alternatively, the duration interval of the QRS complex ismeasured automatically by the medical device programmer once the medicaldevice programmer downloads stored cardiac signals or telemeteredreal-time cardiac signals from the implantable medical device. Theduration interval of the QRS complex is then compare to the series ofrecorded values to classify the complex. Based on the classification ofthe duration intervals of the QRS cardiac complexes at 320, a decisionis made at 330 as to which of the two or more cardiac optimizationmethods will be selected for use.

FIG. 4 shows one example of a sensed cardiac signal 400. In oneembodiment, the cardiac signal 400 is sensed from a surface ECG.Alternatively, the cardiac signal 400 is measured as a far field signalfrom two or more electrodes implanted in or around the heart. The sensedcardiac signal 400 includes examples of a QRS cardiac complex 410. TheQRS cardiac complex 410 is detected in the cardiac signal 400 as theheart goes through the cardiac cycle, and represents the depolarizationphase for the ventricles of the heart. In one embodiment, the durationof the sensed QRS complex 410 is measured from the beginning of theQ-wave 420 to the end of the S-wave 430, where the beginning of theQ-wave 420 is taken as a deflection from a base line 440 for the startof the Q-wave 420, to the return of the cardiac signal to the base line440 at the end of the S-wave 430.

In an alternative embodiment, the duration interval of the QRS complexis measured from portions of the QRS complex sensed in two or morecardiac signals. For example, when a first cardiac signal is sensed froma right ventricle and a second cardiac signal is sensed from a leftventricular location, the duration of the QRS complex is determined bythe difference of the start of the Q-wave in the first cardiac signal tothe end of the S-wave in the second cardiac signal. Alternatively, theduration of the QRS complex is determined by the difference of the startof the Q-wave in the second cardiac signal to the end of the S-wave inthe first cardiac signal. Other methods are possible for determining andmeasuring the duration interval of the QRS cardiac complex and areconsidered within the scope of the present subject matter.

FIG. 5 shows one embodiment of a method 500 according to the presentsubject matter. The method 500 shows an embodiment of a decision treefor providing a suggested optimization algorithm from among multipleoptimization algorithms. As previously discussed, the decision as towhich optimization algorithm is selected among the multiple optimizationalgorithms is based on information that is collected from the patient.This information includes, but is not limited to data stored in theirimplantable device or supplied by the user, such as the location of oneor more implanted leads, conduction disease or disorder (e.g., leftbundle branch block, ischemic dilated cardiomyopathy), current devicesettings, such as lower rate limit, AV-delays, LV-offsets, rateresponsive parameters, minute ventilation data, and conduction patterndata (e.g., intraventricular timing, interventricular timing,atrio-ventricular timing, timing of the sensed QRS-complex and theduration interval of sensed QRS complexes). Based on the information,the method 500 allows for optimization methods and programmable valuesto be suggested for treating the patient. The suggested method can thenbe implemented in the patient's implantable pulse generator.

The embodiment of FIG. 5 shows a decision between the use of the pulsepressure optimization (PPO) algorithm that determines improved settingsbased on candidate therapy-induced changes in heart rate and attempts toimprove pulse pressure, and the maximum pressure versus time algorithm(Max dP/dt algorithm) that determines settings by measuring intrinsicatrio-ventricular (AV) conduction times and attempts to improve the leftventricular contractile function. The embodiment of FIG. 5, however, isonly one example of the decision tree and other decision tree structuresthat use different and/or additional algorithms are possible andconsidered within the scope of the present subject matter.

In the method 500, a decision between use of the PPO algorithm or theMax dP/dt algorithm is made based in part on the duration interval ofthe QRS complex measured from the patient. At 502, the duration intervalof the patient's QRS complex is measured. In one embodiment, neitherfeature (PPO or Max dP/dt) is available unless the duration interval ofthe patient's QRS complex has been measured. One reason for thisrestriction is due to a safety risk of returning a harmful setting ifthe method 500 is performed on QRS duration intervals that have not beenrecently measured from the patient.

As previously mentioned, the PPO algorithm determines improved settingsbased on therapy-induced changes in heart rate and attempts to improvepulse pressure. The PPO algorithm makes use of a dual chamber pacemakerespecially designed for treating congestive heart failure. The deviceincorporates a programmed microcontroller that is operative to adjustthe pacing mode-AV delay of the pacemaker so as to achieve improvedhemodynamic performance. Atrial cycle lengths measured during transienttime intervals immediately following a change in the mode-AV delay aresignal processed and a determination is then made as to which particularconfiguration yields improved performance.

The Max dP/dt algorithm determines settings by measuring intrinsicatrio-ventricular (AV) conduction times and attempts to improve the leftventricular contractile function. The device provides a pacing systemfor providing optimal hemodynamic cardiac function for parameters suchas contractility (peak left ventricle pressure change during systole orLV+dP/dt), or stroke volume (aortic pulse pressure) using calculatedatrio-ventricular delays for optimal timing of a ventricular pacingpulse. The Max dP/dt algorithm makes use of multiple ways to provideoptimized timing for ventricular pacing by determining certain intrinsicelectrical or mechanical events in the atria or ventricles that have apredictable timing relationship to the delivery of optimally timedventricular pacing that maximizes ventricular performance. Thisrelationship allows for a prediction of an atrio-ventricular delay usedin delivery of a ventricular pacing pulse relative to a sensedelectrical P-wave of the atrium to establish the optimal pacing timing.

At 502, the duration interval of the patient's QRS complex is measured.In one embodiment, one representative QRS complex is measured and used.Alternatively, an average or median duration interval for two or moreQRS complexes is used. When the duration interval of the QRS complexcannot be measured, the method 500 proceeds to 504, where a display thatno recommendation as to either algorithm is made and that bothalgorithms are not available for use with the implantable pulsegenerator. When the duration interval of the QRS complex is measured at502, the method 500 then proceeds to 506. At 506, the QRS cardiaccomplex is classified as either having a short duration interval or not.In one embodiment, a short duration interval is as described above. Whenthe QRS cardiac complex is classified as a short duration, the method500 proceeds to 510, where the Max dP/dt algorithm is recommended foruse in the pulse generator and the PPO algorithm is made unavailable foruse in the pulse generator. After 510, the method 500 proceeds to 514where determinations for the Max dP/dt algorithm are made and values foruse with the Max dP/dt algorithm are made. A more complete discussion of514 is presented below.

At 506, when the QRS complex is classified as not having a shortduration interval, the method 500 proceeds to 518. At 518, the QRScardiac complex is classified as either having a medium durationinterval, as previously discussed, or not, and whether the patient has acardiac lead located within the anterior cardiac vein. When these twosituations are true, the method 500 proceeds to 510 and then to 514, asdiscussed. However, when either of these two situations is false, themethod 500 proceeds to 520. At 520, the system tests to determinewhether the right ventricle is the permanently programmed chamber pulsegenerator parameter setting or whether a value for an LV offset isgreater than zero (0). For this latter situation, the system is adaptedto provide biventricular pacing, where ventricular pacing pulses aredelivered initially to the right ventricle and then to the leftventricle, or vice versa, where the two pacing pulses are offset by theLV offset value.

When either of these conditions is true, the method 500 proceeds to 524.At 524, the PPO algorithm is recommended for use and the Max dP/dtalgorithm is made unavailable for use. Different functions for the MaxdP/dt algorithm are used only to set the AV delay when biventricular(i.e., both left and right ventricular (BV)) or left ventricular (LV)pacing is indicated by independent means and BV or LV is the permanentlyprogrammed chamber and LV offset is not positive. Each of the functionsfor the Max dP/dt algorithm are used under different cardiac conditionsdepending upon the location and number of the cardiac electrodespositioned in and around the heart.

The PPO algorithm is then executed at 530 to determine if the algorithmwill fail or succeed. In one embodiment, success is when the PPOalgorithm executes correctly to completion and returns a valid result,and failure is when the PPO algorithm is unable to complete itsexecution or returns an error result. In one embodiment, the systemcancels the PPO algorithm and restores the device to its permanent modeparameter settings and operation if any of the following conditionsoccur. First, if the system cannot determine the patient's intrinsic AVdelay within the maximum time limit allowed. Second, the PPO algorithmextends beyond the maximum total cardiac cycles allowed. Third, whenvalid PPO measurements are collected for less than 3 out of 5 trials ofany configuration of pacing chambers and AV delay. A trial of aconfiguration is defined as 5 intrinsic beats plus 5 beats paced in theconfiguration plus 10 intrinsic beats constituting a washout period. Atransient change in valid PPO measurements resulting from the pacedbeats, compared to the valid PPO measurements resulting from theintrinsic beats that precede the paced beats, provides an indication ofthe effectiveness of the paced beats compared to the effectiveness ofintrinsic beats. To avoid inaccuracies due to noise, randomization andaveraging techniques are used to extract data from the repeated trialsof each configuration. The particular configuration that results in thelargest increase in valid PPO measurements is then utilized in anattempt to optimize the pulse pressure performance of the patient'sheart. A trial is classified as an invalid trial if any of the followingconditions occur. If a premature ventricular contraction (PVC) or apremature atrial contraction (PAC) is detected anywhere during thetrial, or if noise is detected in atrial or ventricular channels duringthe pacing period. These invalid trials are immediately re-tried once inan attempt to make it a valid trial. A valid trial that fails apost-execution outlier test is declared to be an invalid trial. Theseinvalid trials cannot be retried because they are determinedpost-execution. A washout period precedes any trial or re-trial attempt.A washout period is classified as invalid on the cardiac cycle where aPVC or PAC is detected. An invalid washout period is immediatelyre-tried for up to the maximum time limit allowed after the firstcardiac cycle that initiated the washout.

When the PPO algorithm is indicated to have failed at 530, the method500 proceeds to 536. At 536, no results for either algorithm arepresented to the physician and the PPO algorithm is not recommended. Themethod then returns to 520, where one or both of the permanent chambersand/or the value for the LV offset could be changed. This would allowthe method 500 to proceed to 534, instead of 524. Alternatively, the PPOalgorithm is executed at 530 and returns a valid result (“succeed”) andthe method 500 then proceeds to 538. At 538, the PPO algorithm is usedto determine suggested pacing chambers for the patient, along withvalues for the AV offset. In addition to these suggestions, the PPOalgorithm suggests the LV offset be set at the value initiallyprogrammed.

At 520, when both situations are not true, however, the method 500proceeds to 534. At 534, the PPO algorithm is recommended and the MaxdP/dt algorithm is made available for use by the physician. In oneembodiment, the PPO algorithm is recommended when the optimal pacingchamber is unknown and when the maximum output (pulse pressure or strokevolume) is the desired result. With respect to the availability of theMax dP/dt algorithm, when the physician desires a faster optimizationmethod (e.g., less than 20 minutes) due to limited examination time orthe maximum force (LV dP/dt_(max)) is the desired result, the Max dP/dtalgorithm is recommended to set the AV delay.

From 534, a decision is made to proceed with either the PPO algorithm orthe Max dP/dt algorithm. When the PPO algorithm is chosen, the methodproceeds to 530. Alternatively, when the Max dP/dt algorithm is chosenat 534, the method 500 proceeds to 540. At 540, determinations for theMax dP/dt algorithm are made and values for use with the Max dP/dtalgorithm are determined. In one embodiment, determinations and thevalues for the Max dP/dt algorithm at 540 are similar to those made at514. Thus, the following discussion pertains to both 514 and 540.

When the Max dP/dt algorithm is executed at 514 and 540, intervalmeasurements between cardiac events are measured according to the MaxdP/dt algorithm. When these values are within a specified range ofvalues that are determined to be acceptable for determining arecommended pacing chamber, or chambers, an LV offset and/or an AV delayvalue, the method 500 proceeds to 550 from 514, or to 554 from 540. Whenthe values are not within the specified range of values determined to beacceptable for determining a recommended pacing chamber, or chambers, anLV offset and/or an AV delay value, either 514 or 540 proceed to 560. At560, no results are returned for the recommended pacing chamber, orchambers, the LV offset and/or the AV delay value, and an explanation asto why no results were returned is provided. In addition, suggestionsfor alternative approaches for arriving at suggested results could begiven.

As previously discussed, parameter settings for the optimizationalgorithm, such as those at 514, 530 or 540, are tested to determinewhether they are within acceptable value ranges. When the parametersettings for an optimization algorithm are within the acceptable valueranges (e.g., the algorithm succeeds), recommendations as to theparameter settings are made as shown at 538, 550 and 566 or 570. Whenthe parameter settings for the optimization algorithm are not within theacceptable value ranges (e.g., the algorithm fails), adjustments to theparameter settings might be made so that the parameter settings for theoptimization algorithm are within the acceptable value ranges. In oneembodiment, there are three options available to adjust the testing ofthe optimization algorithm. The first option is to discontinue theexecution of the optimization thus providing no recommendation. In FIG.5, this option leads to one of 536 or 560. The second option is toadjust one or more of the parameters to place possible recommendationsback within an acceptable range prior to continuing the cardiacoptimization method. The adjustment of the parameters could beautomatic, or based upon input from the user. The third is to modify theremaining portion of the optimization method to use only combinations ofthe parameters that are within the acceptable range. When one of thelatter two options are used, the method succeeds and proceeds to one of538, 550, 566 or 577.

As a part of the adjustments to the parameter settings that take placein 514, 530 or 540 the present subject matter includes value ranges andrules for which the parameter values are compared and analyzed against.As an initial part of the analysis, a verification is made that the AVdelay to the first pacing pulse delivered is in the range of 50 to 250milliseconds. This is done so that the AV delay is within an acceptableclinical range. A verification is also made that a second pace for theAV delay is always delivered before the intrinsic AV delay and notlonger than the maximum programmable AV delay. If this second-pace“out-of-bounds” rule is violated prior to testing the AV delay, the AVdelay or the LV offset can be shortened until the second pace is nolonger out-of-bounds. Alternatively, the AV delay to be tested can beeliminated from the test or an alternative algorithm can be selectedthat will not require testing of this AV delay. For example, if PPO isselected but the AV delay to be tested results in an out-of-boundssecond pace, the Max dP/dt algorithm may be selected instead. If thesecond-pace out-of-bounds rule is violated after the optimizationalgorithm has finished executing, the resulting AV delay or the LVoffset can be shortened until the second pace is no longer out-of-boundsor the algorithm can return a “fail” result.

At 554, the method 500 then determines whether the system includes aleft ventricular lead and, if so, is the left ventricular lead islocated in the anterior vein of the patient's heart. When true, themethod 500 proceeds to 566. When false, the method proceeds to 570. Ineach of 550, 566 and 570, the Max dP/dt algorithm, along with additionalalgorithms, are used to recommend an AV delay value for pacing in theatrium and the ventricle, which of the ventricular chamber, or chambers,to provide pacing in, and when biventricular pacing is recommended alongwith a recommended LV offset value.

In one embodiment, for both 514 and 540 the Max dP/dt algorithm isrepresented by the equation AV=k1*PR+k2−LV offset. The Max dP/dtalgorithm includes different k1 and k2 coefficient values for threedifferent functions, F1, F2 and F3, of the Max dP/dt algorithm equation,where each of the functions F1, F2 and F3 are used in 550, 566 and 570,respectively. Each of the equations for the Max dP/dt algorithm are usedunder different cardiac conditions depending upon the location andnumber of the cardiac electrodes positioned in and around the heart.

With respect to 550, the function F1 of the Max dP/dt algorithm is alinear function of the PR interval measured from an atrial sense markerto a first ventricular sense marker (1st PR). In one embodiment, thesense markers indicate where the cardiac event was determined to haveoccurred as the cardiac signal was sensed. In addition, the firstventricular sense marker is taken as the first of either a leftventricular depolarization or a right ventricular depolarization in abiventricular pacing/sensing system.

Function F1 is intended to set the AV delay value just shorter than theshortest intrinsic AV delay. In one embodiment, the shortest AV delay istaken as the PR interval measured from the atrial sense marker to thefirst ventricular sense marker (1st PR). For function F1, the PRinterval is determined from the atrial sense marker to the 1 stventricular sense marker plus a constant offset value “d”. The constantoffset value d is added to the PR interval to adjust for the differencebetween the ventricular sense marker and the time of the peak R-wavedepolarization that was originally used to derive the coefficients k1and k2. In one embodiment, the constant offset value “d” is set in arange of 10 to 100 milliseconds. For F1, coefficient k1 is equal to 0.70and coefficient k2 is equal to zero (0.0). Also in 550, a recommendationfor pacing in both the right and left ventricles (biventricular) ismade, along with setting the LV offset from the right ventricular pacingpulse to zero (0.0). However, it is also valid to use the AV delay fromthe F1 Max dP/dt formula with other pacing chambers, such as the rightventricle or the left ventricle, if these are independently selected bythe physician.

With respect to 566, the function F2 of the Max dP/dt algorithm is alinear function of the PR interval measured from an atrial sense markerto a right ventricular sense marker (RV PR). In one embodiment, thesense markers indicate where the cardiac event was determined to haveoccurred as the cardiac signal was sensed. In addition, the rightventricular sense marker is taken as the indicator of the depolarizationof the right ventricle. For function F2, the PR interval is determinedfrom the atrial sense marker to the right ventricular sense marker plusthe constant offset value “d”, as previously described. In oneembodiment, coefficient k1 is equal to 0.75 and coefficient k2 is equalto −60 for function F2. Also at 566, a recommendation for pacing in theventricular chambers as originally programmed and allowing the LV offsetto remain as programmed (negative or zero) are recommended for use withthe Max dP/dt algorithm.

With respect to 570, the function F3 of the Max dP/dt algorithm is alinear function of the PR interval measured from an atrial sense markerto a right ventricular sense marker (RV PR). In one embodiment, thesense markers indicate where the cardiac event was determined to haveoccurred as the cardiac signal was sensed. In addition, the rightventricular sense marker is taken as the indicator of the depolarizationof the right ventricle. For function F3, the PR interval is determinedfrom the atrial sense marker to the right ventricular sense marker plusthe constant offset value “d”, as previously described. In oneembodiment, coefficient k1 is equal to 0.60 and coefficient k2 is equalto −30 for function F3. Also at 570, a recommendation for pacing in theventricular chambers as originally programmed and allowing the LV offsetto remain as programmed (negative or zero) are recommended for use withthe Max dP/dt algorithm.

In one embodiment, the Max dP/dt algorithm of F2 and F3 are notavailable when the pacing chamber is programmed to only the rightventricle, or is programmed to a biventricular mode with a positive LVoffset value (i.e., pacing the right ventricle before the leftventricle). Thus, the F2 and F3 Max dP/dt functions are not valid forthese cases. However, these functions likely can be used whenbiventricular chamber pacing is used and the LV offset is negative. Inone embodiment, when biventricular pacing is used with a negativeoffset, the best AV delay to the left ventricular pace is usuallyconstant regardless of the LV offset. Thus, functionally the LV offsetbehaves as if it is an RV offset, that is, the best AV delay topre-excite the left ventricle is constant and improvement in the cardiacfunction is seen by pacing the right ventricle after the left ventriclerather than simultaneously. This means that the Max dP/dt algorithmfunctions to return the AV delay that is the best time to pace the leftventricle, and not the right ventricle. Therefore, to adjust for rightventricular timing, the Max dP/dt algorithms are modified to add the LVoffset (subtract the negative offset) to the computed AV delay so the AVdelay represents the right ventricular pace delay and the LV offsetpaces the left ventricle at the correct time.

FIG. 6 is a schematic drawing illustrating, by way of example, but notby way of limitation, one embodiment of a system 600 that includes animplantable pulse generator 602 and a medical device programmer 640. Theimplantable pulse generator 602 is shown coupled by leads 604, 606 and608 to a heart 610. In the present embodiment, the pulse generator 602provides for biventricular therapy to coordinate right ventricular andleft ventricular contractions, such as for congestive heart failurepatients. The pulse generator 602 also contains control circuitry withinhousing 612 that receives and analyzes cardiac signals sensed andprovides energy pulses with the leads 604, 606 and 608 under certainpredetermined conditions.

In one embodiment, lead 604 is shown with a first atrial sensing/pacingelectrode 614 and a second atrial sensing/pacing electrode 616. In oneembodiment, the first atrial sensing/pacing electrode 614 is a tipelectrode located at a distal end 617 of lead 604. Alternatively, firstatrial sensing/pacing electrode 614 is a ring electrode that partiallyor completely encircles the lead body of lead 604 at a position proximalto the distal end 617. In an additional embodiment, the second atrialsensing/pacing electrode 616 is a ring electrode that partially orcompletely encircles the lead body of lead 604 and is positionedproximal to both the distal end 617 and the first atrial sensing/pacingelectrode 614. Lead 604 is adapted to be implanted in a supraventricularregion 618 of the heart 610, where the body of lead 604 includes aJ-curve 620 near the proximal end 616 to allow the distal end 617 to beimplanted into the endocardium of the heart 610. In one embodiment, thedistal end 617 of lead 604 is implanted in the right atrial appendage toallow for a cardiac signal to be sensed from the supraventricular regionof the heart. In another embodiment, the distal end 617 is implanted atthe right atrial septum between Koch's triangle and Bachmann's bundle.In the embodiment shown in FIG. 6, the cardiac signal is sensed from andfor electrical energy pulses (e.g., pacing level pulses) to be deliveredto the right atrium of the heart 610. In one embodiment, the cardiacsignal sensed with lead 604 is a bipolar cardiac signal sensed betweenthe first and second atrial sensing/pacing electrode 614 and 616.Alternatively, a unipolar cardiac signal is sensed between either thefirst or second atrial sensing/pacing electrode 614 or 616 and thehousing 612.

In one embodiment, lead 606 is shown with a first left ventricularsensing/pacing electrode 622 and a second left ventricularsensing/pacing electrode 624. In one embodiment, the first leftventricular sensing/pacing electrode 622 is a tip electrode located at adistal end 626 of lead 606. Alternatively, first left ventricularsensing/pacing electrode 622 is a ring electrode that partially orcompletely encircles the lead body of lead 606 at a position proximal tothe distal end 626. In an additional embodiment, the second leftventricular sensing/pacing electrode 624 is a ring electrode thatpartially or completely encircles the lead body of lead 606 and ispositioned proximal to both the distal end 626 and the first leftventricular sensing/pacing electrode 622. In an alternative embodiment,lead 608 can include only the first left ventricular sensing/pacingelectrode 622, without the second left ventricular sensing/pacingelectrode 624.

Lead 606 is adapted to be implanted into the heart 610 with the distalportion of the lead 606 positioned in an epicardial location adjacentthe left ventricle 628. In one embodiment, the distal end 626 of lead606 is inserted through the coronary sinus vein 629, thence through thegreat cardiac vein and into a lateral branch of the left ventricularcoronary vasculature to position the first and second left ventricularsensing/pacing electrodes 622 and 624 adjacent the lateral wall of theleft ventricle 628 to allow for a cardiac signal to be sensed from andfor electrical energy pulses (e.g., pacing level pulses) to be deliveredto the left ventricular region of the heart. In one embodiment, thecardiac signal sensed with lead 606 is a bipolar cardiac signal sensedbetween the first and second left ventricular sensing/pacing electrode622 and 624. Alternatively, a unipolar cardiac signal is sensed betweeneither the first or second left ventricular sensing/pacing electrode 622or 624 and one or more electrodes implanted in the right ventricle.Examples of these right ventricular electrodes are described below inconjunction with lead 608. Alternatively, the housing 612 can be used asthe return electrode (anode) with either the first or second leftventricular sensing/pacing electrode 622 or 624.

In one embodiment, lead 608 is shown with a first right ventricularsensing/pacing electrode 630 and a second right ventricularsensing/pacing electrode 632. In one embodiment, the first rightventricular sensing/pacing electrode 630 is a tip electrode located at adistal end 634 of lead 608. Alternatively, first right ventricularsensing/pacing electrode 630 is a ring electrode that partially orcompletely encircles the lead body of lead 608 at a position proximal tothe distal end 634. In an additional embodiment, the second rightventricular sensing/pacing electrode 632 is a ring electrode thatpartially or completely encircles the lead body of lead 608 and ispositioned proximal to both the distal end 634 and the first rightventricular sensing/pacing electrode 630. Lead 608 is adapted to beimplanted in a right ventricular region 635 of the heart 610. In oneembodiment, the distal end 634 of lead 608 is implanted in the apex ofthe right ventricle 635 to allow for a cardiac signal to be sensed fromand for electrical energy pulses (e.g., pacing level pulses) to bedelivered to the right ventricular region of the heart 610. In anotherembodiment, the distal end 634 of lead 608 is implanted at the rightventricular septum between the right ventricular apex and outflow tract.In one embodiment, the cardiac signal sensed with lead 608 is a bipolarcardiac signal sensed between the first and second right ventricularsensing/pacing electrode 630 and 632. Alternatively, a unipolar cardiacsignal is sensed between either the first or second right ventricularsensing/pacing electrode 630 or 632 and the housing 612.

In an additional embodiment, any one of the leads 604, 606 or 608 caninclude additional electrodes attached to the lead body. Examplesinclude, but are not limited to, the leads further including one or moreadditional sensing/pacing electrodes and/or one or more defibrillationcoil electrodes. In addition, cardiac signals and energy pulsesdelivered by the electrodes can be delivered in any number of additionalways, including, but not limited to, cardiac signals and energy pulsesbeing delivered between two or more of any combination of sensing/pacingelectrodes shown in FIG. 6 or additional electrodes that might be addedto the pulse generator 602 of FIG. 6.

Pulse generator 602 further includes components, such as the electroniccontrol circuitry, enclosed in the housing 612. Additional electrodesmay be located on the housing 612, may be the housing 612 itself, may beon an insulating header 636, or on other portions of the pulse generator602, for providing unipolar or bipolar pacing/sensing and/ordefibrillation energy in conjunction with the electrodes disposed on oraround heart 610. Other forms of electrodes include meshes and patcheswhich may be applied to portions of heart 610 or which may be implantedin other areas of the body to help “steer” electrical currents producedby the generator 602. The present method and apparatus will work in avariety of configurations and with a variety of electrical contacts or“electrodes.”

The system 600 further includes medical device programmer 640 thatprovides for wireless communication with the electronic controlcircuitry within the pulse generator 602. The medical device programmer640 is adapted to be positioned outside the human body for communicationwith the pulse generator 602. Communication between the electroniccontrol circuitry within the pulse generator 602 and the medical deviceprogrammer 640 occurs over a communication link 642 that is establishedbetween programmer 640 and the pulse generator 602 through the use of atelemetry device 644. In one embodiment, the telemetry device 644 isinductively coupled to control circuitry within the medical deviceprogrammer 640. In another embodiment, the communication linkestablished between the programmer 640 and the pulse generator 602 is aradio frequency link.

In one embodiment, the medical device programmer 640 includes electroniccircuitry within a housing 646, where a graphics display screen 648 isdisposed on an upper surface of the housing 646. The programmer 640further includes a drive 650 for reading and writing instructions usedby the electronic circuitry of the programmer 640. The graphics displayscreen 648 is operatively coupled to the electronic circuitry within thehousing 646 and is adapted to provide a visual display of graphicsand/or data to the user.

The programmer 640 further includes input devices to the electroniccircuitry. For example, the programmer 640 includes a touch-sensitivedisplay screen, such that the user interacts with the electroniccircuitry by touching identified regions of the screen with either theirfinger or with a stylus. In addition, the programmer 640 furtherincludes an alphanumeric key board 652 for providing information, suchas programmable values for the implantable medical device, to theelectronic circuitry in the medical device 602. FIG. 6 also shows theprogrammer 640 having a printer 654 which allows for cardiac signalsreceived from the implantable medical device 602 to not only bedisplayed on the graphics display screen 648, but also to be displayedon a paper printout 656. Adjustments for printer speed and scale of theprinted cardiac signals is adjustable through the use of the displayscreen 648 and the electronic circuitry within the programmer 640.

In one embodiment, the present subject matter is executed using only theelectronic control circuitry within medical device programmer 640.Alternatively, the present subject matter is executed using theelectronic control circuitry within both the medical device programmer640 and the implantable medical device 602. In this latter embodiment,the electronics within each of the devices 602 and 640 perform variousportions of the algorithm of the present subject matter and thealgorithms of the optimization algorithms. In one embodiment, theprogrammer is used to direct and control the execution of the presentsubject matter. Thus, most of the subject matter discussed for FIGS. 1-5is executed in the control circuitry of the medical device programmer,where the programmer uses the pulse generator to retrieve patientspecific data from the pulse generator and cardiac signals sensedthrough the use of the pulse generator. Once the programmer has receivedthis information, the programmer executes a decision tree, such as theexample of FIG. 5. Once a decision as to a recommended optimizationalgorithm, and the parameters to be used, is arrived at, the programmercan then be used to program the pulse generator to perform anoptimization test. In one embodiment, the optimization test is used todetermine if the parameters determined by the programmer for theoptimization algorithm are acceptable and functional in the pulsegenerator. After the control circuitry of the pulse generator completesthe optimization test, the results of the test are returned to theprogrammer for analysis by the programmer and/or the physician.

FIG. 7 shows one embodiment of the control circuitry for both themedical device programmer 640 and the implantable pulse generator 602that comprise system 600. In one embodiment, both the implantable pulsegenerator 602 and the medical device programmer 640 aremicroprocessor-based devices. In one embodiment, the system 600 includesa cardiac signal feature extractor to measure one or more features froma cardiac signal, a cardiac algorithm optimizer, where the cardiacalgorithm optimizer selects a cardiac optimization method from two ormore cardiac optimization methods based in part on the measured featuresfrom the cardiac signal, and a controller that executes the selectedcardiac optimization method. In one embodiment, these components of thesystem 600 are divided between the implantable pulse generator 602 andthe medical device programmer 640 so that both devices are used inexecuting the methods of the present subject matter. Alternatively,these components of system 600 are included in only one of either theimplantable pulse generator 602 or the medical device programmer 640.FIG. 7 shows one embodiment where the components of the system 600 aredivided between the implantable pulse generator 602 and the medicaldevice programmer 640.

In one embodiment, the medical device programmer 640 includes programmercontrol circuitry 700 having data input/output 702, memory 704,controller 706, cardiac algorithm optimizer 710, transmitter/receiver712, power source 714 and printer 716. The controller communicates withthe associated circuitry (e.g., data input/output 702, memory 704,controller 706, cardiac algorithm optimizer 710 and transmitter/receiver712) via bus 718. In one embodiment, the data input/output 702 includesread/write drives and data transfer between the control circuitry andthe keyboard and screen.

In one embodiment, the implantable pulse generator 602 includes pulsegenerator control circuitry 720 having signal input/output 724, memory726, controller 728, cardiac signal feature extractor 730,transmitter/receiver 732, and a power source 734. The controllercommunicates with the associated circuitry (e.g., signal input/output724, memory 726, controller 728, cardiac signal feature extractor 730and transmitter/receiver 732) via bus 740. In one embodiment, the signalinput/output 724 includes connectors for coupling to the electrodeslocated on the leads, amplifiers for amplifying cardiac signals sensedwith the electrodes and controls for generating and deliveringelectrical energy pulses to the electrodes. In addition, thetransmitter/receiver 732 is adapted to establish a communication linkwith the transmitter/receiver 712 of the medical device programmer 640to allow for patient specific information, including cardiac signalssensed from the patient, to be transferred between the two devices.

In the present example, the cardiac signal feature extractor 730 of theimplantable pulse generator 602 is used to measure one or more featuresfrom a cardiac signal, the cardiac algorithm optimizer of the medicaldevice programmer 640 is used to select a cardiac optimization methodfrom two or more cardiac optimization methods based in part on themeasured features from the cardiac signal and the controller 706 of themedical device programmer 640 or the controller 728 of the implantablepulse generator 602 are used to execute the selected cardiacoptimization method.

In one embodiment, when the system 700 is used to select a cardiacoptimization method, the implantable pulse generator 602 is used tosense one or more cardiac signals from the heart. From the sensedcardiac signals, the programmer 640 is used to identify a cardiacoptimization method from two or more methods for use in the pulsegenerator 602, as previously described. Once the cardiac optimizationmethod is identified it is tested to determine whether the parametervalues suggested for use with the optimization method can be used withthe pulse generator 602, as previously described. To accomplish thistask, the cardiac signal feature extractor 730 measures features fromthe cardiac signal during the execution of the selected cardiacoptimization method, as previously discussed, and records the featuresmeasured during the cardiac optimization method. The controller 706 alsoacquires additional patient information via a transmitter/receivertelemetry link during the cardiac optimization method. The cardiacalgorithm optimizer 710 then adjusts the execution of the cardiacoptimization method based on the recorded features measured during thecardiac optimization method and the additional patient information.

In one embodiment, the cardiac algorithm optimizer 710 determinesparameter values for use with the cardiac optimization method based onthe recorded features and the additional patient information. In oneembodiment, the cardiac algorithm optimizer 710 analyzes the parametervalues to determine whether the values are within acceptable valueranges, where the acceptable value ranges are stored in memory 704. Aspreviously discussed, there are several options in responding to thesituation where the parameter values are not within acceptable valueranges. One option is for the programmer 640 to make no recommendationand to discontinue the execution of the optimization method.Alternatively, the cardiac algorithm optimizer 710 adjusts the parametervalues to place the parameter values within acceptable value ranges.Finally, the cardiac algorithm optimizer 710 could be used to makeadjustments to the remaining portion of the optimization method (e.g.,additional parameter values) to only use combinations of the parametersthat are within the acceptable range.

As previously discussed, the adjustments to the optimization algorithmsoccur once an algorithm has been identified based on measured portionsof the sensed cardiac signals (e.g., QRS duration), location of theimplanted leads, and/or values for an LV offset. FIG. 5 was one suchexample. In one embodiment, the system 700 is used in making a decisionbetween the use of the pulse pressure optimization (PPO) algorithm andmaximum pressure versus time algorithm (Max dP/dt algorithm). Aspreviously discussed, the decision between use of the PPO algorithm orthe Max dP/dt algorithm is made based in part on the duration intervalof the QRS complex. In one embodiment, the cardiac signal featureextractor 730 measures the duration interval of the QRS cardiac complexin the sensed cardiac signal. The cardiac algorithm optimizer 710 thencompares the duration interval to the series of recorded values. Thecardiac algorithm optimizer 710 then selects the cardiac optimizationmethod based on the comparison of the duration interval to the series ofrecorded values, as previously discussed.

In one embodiment, the cardiac algorithm optimizer 710 classifies theduration interval as either a short duration interval or a mediumduration interval. In one embodiment, when the duration interval isclassified as the short duration interval, the cardiac algorithmoptimizer 710 recommends a Max dP/dt algorithm and makes a pulsepressure optimization algorithm unavailable. The cardiac algorithmoptimizer 710 then determines values for use with the Max dP/dtalgorithm and the controller 706 executes the Max dP/dt algorithm todetermine whether the suggested parameter values can be used with thepulse generator 602. In one embodiment, the cardiac signal featureextractor 730 is used to measure intervals between cardiac events, wherethe cardiac algorithm optimizer 710 determines whether the intervals arewithin a specified range of values. The cardiac algorithm optimizer 710then recommends one or more pacing chambers, and an LV offset or an AVdelay value when the intervals are within the specified range of values.In one embodiment, the cardiac algorithm optimizer 710 recommendsbiventricular chamber pacing and the LV offset equal to zero, andcalculates the AV delay from the linear function from the PR intervalmeasured from an atrial sense marker to a first ventricular sensemarker, as previously discussed. However, when the intervals are notwithin the specified range of values, the cardiac algorithm optimizer710 does not recommend one or more pacing chambers and the LV offset orthe AV delay value, as previously discussed.

In an additional embodiment, the cardiac algorithm optimizer 710recommends the Max dP/dt algorithm and makes the pulse pressureoptimization algorithm unavailable when the cardiac signal featureextractor 730 determines a cardiac lead is located within the anteriorcardiac vein and the duration of the QRS complex is classified as themedium duration interval. In one embodiment, the controller 706 executesthe Max dP/dt algorithm when the cardiac lead is located within theanterior cardiac vein using values for the Max dP/dt algorithmdetermined with the cardiac signal feature extractor 730. As the MaxdP/dt algorithm is executed, the cardiac signal feature extractor 730measures intervals between sensed cardiac events. The cardiac algorithmoptimizer 710 then determines whether the intervals are within thespecified range of values, as previously discussed. When the intervalsare within the specified range of values, the cardiac algorithmoptimizer 710 recommends one or more pacing chambers and values for theLV offset and the AV delay. In one embodiment, the cardiac algorithmoptimizer 710 recommends biventricular chamber pacing, the LV offsetequal to zero and calculates the AV delay from the linear function usingthe PR interval measured from an atrial sense marker to a firstventricular sense marker, as previously described, when the intervalsare within the specified range of values. However, when the intervalsare not within the specified range of values, the cardiac algorithmoptimizer 710 does not provide recommendations for one or more pacingchambers or values for the LV offset and the AV delay.

In an alternative embodiment, when either a right ventricle is thepermanently programmed chamber or the value for an LV offset is greaterthan zero, then the cardiac algorithm optimizer 710 recommends the PPOalgorithm and makes the Max dP/dt algorithm unavailable. The controller728 then executes the PPO algorithm and determines whether the pulsepressure optimization algorithm fails or succeeds, as previouslydiscussed. If the PPO algorithm fails, then the cardiac algorithmoptimizer 710 returns no result and the PPO algorithm is notrecommended. However, if the controller 728 determines the PPO algorithmsucceeds, then the cardiac algorithm optimizer 710 determines suggestedpacing chambers for the patient and determines values for an AV offsetfrom the pulse pressure optimization algorithm, and suggests the LVoffset be set at an initially programmed value.

In an alternative embodiment, when either the right ventricle is not thepermanently programmed chamber or the value for the LV offset is lessthan or equal to zero, then the cardiac algorithm optimizer 710recommends the PPO algorithm. The controller 728 then executes the PPOalgorithm and determines whether the PPO algorithm fails or succeeds, aspreviously discussed. If the PPO algorithm fails, then the cardiacalgorithm optimizer 710 returns no result and the PPO algorithm is notrecommended. However, if the controller 728 determines the PPO algorithmsucceeds, then the cardiac algorithm optimizer 710 determines suggestedpacing chambers for the patient and determines values for the AV offsetand suggests the LV offset be set at an initially programmed value.

In an additional embodiment, the cardiac algorithm optimizer does notrecommend one or more pacing chambers, the LV offset or the AV delayvalue when the measured intervals between the cardiac events for usewith the Max dP/dt algorithm are not within the specified range ofvalues and the left ventricular lead position is in an anterior vein.Alternatively, the cardiac algorithm optimizer 710 recommends one ormore pacing chambers and the LV offset to remain as programmed and theAV delay value to be determined from the linear function of the PRinterval measured from the atrial sense marker to the right ventricularsense marker when the intervals are within the specified range of valueswhen the left ventricular lead position is in the anterior vein and whenthe intervals are within the specified range of values, as previouslydiscussed. Finally, the cardiac algorithm optimizer 710 recommends oneor more pacing chambers and the LV offset to remain as programmed andthe AV delay value to be determined from the linear function of the PRinterval measured from the atrial sense marker to the right ventricularsense marker when the left ventricular lead position is not in theanterior vein and when the intervals are within the specified range ofvalues, as previously discussed.

As discussed above, the system illustrated in FIG. 7 may be used toperform any of the cardiac optimization methods described herein. FIG. 8illustrates an exemplary embodiment that may be performed by implantablepulse generator 602 and/or the medical device programmer 640. At step801, the PPO algorithm is performed in which the values of one or moreresynchronization pacing parameters are varied while measuring anintrinsic atrial rate. At step 802, a feature is extracted from anelectrogram signal. At step 803, one or more resynchronization pacingparameters are set based on one or both of the feature extracted from anelectrogram signal and the value of a resynchronization pacing parameterwhich tends to minimize the intrinsic atrial rate.

Although specific embodiments have been illustrated and describedherein, it will be appreciated by those of ordinary skill in the artthat any arrangement which is calculated to achieve the same purpose maybe substituted for the specific embodiment shown. This application isintended to cover any adaptations or variations of the presentinvention. Therefore, it is intended that this invention be limited onlyby the claims and the equivalents thereof.

1. A system, comprising: an implantable pulse generator for deliveringpacing pulses to one or both ventricles, wherein the implantable pulsegenerator is programmed to deliver the pacing pulses in anatrial-triggered pacing mode and in accordance with specified pacingparameters; a processor programmed to extract a feature from a cardiacelectrical signal; and, wherein the processor is further programmed toselect one or more optimum settings of pacing parameters based on theone or more features extracted from an electrogram signal and the valueof a pacing parameter that tends to minimize the intrinsic atrial rate.2. The system of claim 1 wherein the one or more pacing parameters forwhich optimum settings are selected include an AV delay interval.
 3. Thesystem of claim 2 wherein the processor is programmed to select betweenan AV delay that minimizes the intrinsic atrial rate and an AV delaycomputed as a function of the measured intrinsic AV conduction timebased upon the feature extracted from a cardiac electrical signal. 4.The system of claim 3 wherein the processor is programmed to selectbetween an AV delay that minimizes the intrinsic atrial rate and an AVdelay computed as a function of the measured intrinsic AV conductiontime based upon the time required for the ventricles to depolarizeduring an intrinsic beat.
 5. The system of claim 1 wherein the one ormore pacing parameters for which optimum settings are selected includewhich of the ventricles to pace.
 6. The system of claim 1 wherein theone or more pacing parameters for which optimum settings are selectedinclude an LV offset for biventricular pacing.
 7. The system of claim 1wherein the feature extracted from the cardiac electrical signal relatesto the time required for the ventricles to depolarize during anintrinsic beat as indicated by the QRS width of a surfaceelectrocardiogram or a similar feature of an intra-cardiac electrogram.8. The system of claim 7 wherein the feature extracted from a cardiacelectrical signal that relates to the time required for the ventriclesto depolarize during an intrinsic beat is a time difference betweenright and left ventricular senses as detected from intra-cardiacelectrograms.
 9. The system of claim 1 wherein the processor isprogrammed to select between an optimal setting for a pacing parameterthat minimizes the intrinsic atrial rate and a setting that maximizesventricular contractile function based upon the feature extracted fromthe cardiac electrical signal.
 10. The system of claim 1 wherein theprocessor is programmed to select between an optimal setting for apacing parameter that minimizes the intrinsic atrial rate and a settingthat maximizes ventricular contractile function based upon the timerequired for the ventricles to depolarize during an intrinsic beat. 11.A method, comprising: delivering pacing pulses to one or both ventriclesin an atrial-triggered pacing mode and in accordance with specifiedpacing parameters; extracting a feature from a cardiac electricalsignal; and, selecting one or more optimum settings of pacing parametersbased on the one or more features extracted from an electrogram signaland the value of a pacing parameter that tends to minimize the intrinsicatrial rate.
 12. The method of claim 11 wherein the one or more pacingparameters for which optimum settings are selected include an AV delayinterval.
 13. The method of claim 12 further comprising selectingbetween an AV delay that minimizes the intrinsic atrial rate and an AVdelay computed as a function of the measured intrinsic AV conductiontime based upon the feature extracted from a cardiac electrical signal.14. The method of claim 13 further comprising selecting between an AVdelay that minimizes the intrinsic atrial rate and an AV delay computedas a function of the measured intrinsic AV conduction time based uponthe time required for the ventricles to depolarize during an intrinsicbeat.
 15. The method of claim 11 wherein the one or more pacingparameters for which optimum settings are selected include which of theventricles to pace.
 16. The method of claim 11 wherein the one or morepacing parameters for which optimum settings are selected include an LVoffset for biventricular pacing.
 17. The method of claim 11 wherein thefeature extracted from the cardiac electrical signal relates to the timerequired for the ventricles to depolarize during an intrinsic beat asindicated by the QRS width of a surface electrocardiogram or a similarfeature of an intra-cardiac electrogram.
 18. The method of claim 17wherein the feature extracted from a cardiac electrical signal thatrelates to the time required for the ventricles to depolarize during anintrinsic beat is a time difference between right and left ventricularsenses as detected from intra-cardiac electrograms.
 19. The method ofclaim 11 further comprising selecting between an optimal setting for apacing parameter that minimizes the intrinsic atrial rate and a settingthat maximizes ventricular contractile function based upon the featureextracted from the cardiac electrical signal.
 20. The method of claim 11further comprising selecting between an optimal setting for a pacingparameter that minimizes the intrinsic atrial rate and a setting thatmaximizes ventricular contractile function based upon the time requiredfor the ventricles to depolarize during an intrinsic beat.